Critical Components in the Match

Steps 1 & 2, M3 Grades, and Your Residency Match

Your M3 year is arguably the most challenging, exciting, and rewarding part of your medical school training. So much will happen during this year. You will see new life, death, healing, heartbreaking sadness, medical miracles, and much more. As the year progresses, you will also begin to consider the next direction you take within the fields of medicine that you wish to pursue. At some point everyone will ask some form of the question: I want to enter X specialty….what does it take (or do I have what it takes) to get into that field? This document is aimed at providing a least an initial foray into the answer to that question.

To start this conversation, the competitiveness of the major medical specialty fields are categorized into three tiers; Competitive, Moderately competitive, and Less competitive.

Competitive programs that are the most difficult to match into include: Dermatology, General Surgery, Neurosurgery, Orthopedic Surgery, Ophthalmology, Otolaryngology, Plastic Surgery, Urology, Radiology, and Radiation Oncology.

Less competitive specialties include Family Medicine, Internal Medicine,
Pathology, Pediatrics, Physical Medicine and Rehabilitation, and Psychiatry.

These categories are meant to provide a general guideline, but know
that there is fluidity, and nuance to these categories and that the boundaries
between them are not fixed. Also, any one program can be considered more competitive
depending on other variables such as program location, prestige, etc. For example,
despite that internal medicine is categorized as a “less competitive” specialty, the most highly respected and renowned Internal Medicine residency programs are highly competitive and therefore difficult to get into. Exceptions in the opposite direction generally do not hold up as well. That is, the least prestigious Dermatology program in the least desirable location….is still likely a highly competitive program as there are consistently many more applicants in Dermatology than there are available slots across the country.

In order to be a strong candidate for competitive specialties, one
must have at least a “very good” academic profile. What is a very good academic profile? The following paragraphs will shed light on this question.

As a general rule, there are 3 criteria that are often most critical to your residency application: Step 1, Step 2, and Clinical grades. We will classify these 3 most important criteria as “Class A” parts of your residency application.
Although an oversimplification, it can be helpful to think about match prospects in the following manner. A student can “underperform” on one of the Class A parts, and recover by doing very well on the other two parts. Low performance on 2 parts however, quite likely limits match possibilities to less competitive specialties. And low performance on all 3 Class A criteria almost certainly narrows one’s match possibilities.

USMLE Step one is the first Class A part of your application. A discussion of Step 1 will be approached first by breaking down scores into 4 separate categories. The scores used to create the boundaries of each category are somewhat arbitrary, but they provide a starting place for explanation.

Passing-200 Sub 200 scores are considered low. It is very important to remember that students who score in this range still have 2 other critical Class A criteria where they can show improvement. Both UMMS and national AAMC Match data suggests however that sub 200 step one scores will likely start to limit a student’s match possibilities to the lesser competitive specialties.

200-220 This range is considered “OK-good”. Still, at the lower end of this range, some limitations in the match process may occur. A score in this range (especially at the upper end of the range) however, paired with solid performances on the other 2 pieces can keep some doors in the more competitive categories open.

220-240 This range is considered very good. Students with scores in this range will likely have most all doors open to all specialties especially if paired with at least good performances on on Step 2 and clinical grades.

240 and above. Scores in this range are considered excellent. These scores are viewed very positively by program directors and serve to significantly bolster the match possibilities for applicants. Scores in this range serve to allow for all specialties to remain in contention for matching. However, a strong Step 1 score alone is not in and of itself enough to ensure a match into a competitive specialty. Students must have other strong data to support a very strong Step 1 score.

By far the vast majority of the class finishes the M3 year with a mixture of clinical grades. Program directors highly value clinical performance as this criterion reflects much more than a score on a test. Student’s teamwork, dedication, knowledge base, bedside manner, communication, handling of difficult patients, clinical skills, work ethic, etc. are all part of what is attempted to be captured by your clinical evaluations. Final, clinical grades are always determined most significantly by a combination of clinical evaluations and shelf scores. As is published in your M3 handbook, the M3 year is graded on an Honors (top 10-15%), High Pass (35-45%), Pass (45-55%) system. The percentage targets can vary slightly between clerkships, but not significantly so.

It is a statement of the obvious, but the more Honors and High Passes earned, the better the clinical record. Conversely, the more Passes on the M3 transcript, the lower the record. Despite that a Pass grade represents an adequate performance, Passes across the entire M3 year constitutes a low clinical performance. A low clinical performance paired with a low Step one score almost certainly limits a student to consider only the less competitive specialties.

There are several more important points to consider. Honors grades are difficult to earn, but be aware that an all High Pass record across the M3 year is a very good performance. Of course, any Honors grades are always helpful, but there is often a misperception that “many” Honors grades are needed to match well in competitive sub specialties. For the most desirable programs (big cities in coastal areas: San Francisco, Boston, Seattle, etc.) in the more competitive specialties, at least some honors scores are likely needed to make one’s application viable.

The categories of scores listed above for Step 1 and the impact on matching applies to Step 2 CK as well. Do know however, that the mean scores for Step 2 are generally approximately 10 points higher for Step 2 CK, so all the categories score boundaries (discussed above re Step 1) should be increased by 10 points.

Remember, for any student that experiences a bad test day, bad test, interrupted study period, etc. for Step 1....know that a good performance on the Step 2 CK exam can go a long way in countering the effects of a disappointing step 1 score. Especially in this situation, the Step 2 CK should be, a) taken as soon as the M3 year is complete and, b) taken after using an M4 vacation month for maximum preparation. Also, most program directors are well aware that Step 2 CK is a much better indicator of the type of intern you will be as compared to Step 1. Therefore a good, solid, (and early reported) Step 2 CK score can go a long way in boosting a student’s application.

Class B criteria: Interviews

Of the non Class A criteria, the Interview is arguably the criteria that can carry the most potential for a being a “game changer.” Think of your residency application process in two steps. The first step is a “paper” you; your CV, scores, grades, etc. The paper you, gives a lot of information, but the paper you….is not all of you. That is why programs want to see you, ask questions, listen, look into your eyes, shake your hand, ---and get a sense of the YOU….that can’t be obtained from words on paper. For these reasons the interview is a potentially powerful part of the process that can sometimes help a student get into a program that their academic record alone would not predict. But for everyone, a good interview where you display courtesy, kindness, interest, respect, humane qualities, asking insightful questions, etc. can always help your chances with any program.

In general, the Class C criteria can all be seen as the “supporting cast” of criteria. These variables tend to be used for making finer distinctions…when all else between potential candidates seems equal in comparison. These criteria rarely help a student get a match into a specialty if one’s academic record (Class A variables) are less competitive. Nevertheless, these class C variable should not to be ignored, and in some cases, some Class C variables can sometimes rise to a Class B criteria in importance. For instance, research oriented fields (e.g. Radiology, Plastic Surgery, Radiation Oncology, etc.) will often more highly value research experience and scholarly work. Similarly, residencies that are academically oriented will understandably more highly value research and publications.

Parting thoughts:

All students entering the match should visit the AAMC Careers in Medicine Website https://www.aamc.org/students/medstudents/cim/ to obtain more detailed information about specialties. Of particular relevance is the AAMC/NRMP document Charting Outcomes in the Match (just search on the CIM website) which provides the most current data on the match process broken down by specialty. It is essential to be well informed and these resources contain a plethora of excellent information that is invaluable.

This document is an attempt to provide some very fundamental information and perspective on the criteria that have bearing on the match process. Know however, that there is a good bit of nuance to matching, and so it is still very important to get individualized feedback on your career decisions and residency application process from Faculty, Faculty Career Advisors, OMSE Deans, and Class Counselors.